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Original Question
OHN DUNCAN Initial Nursing Assessment Day 1 @ 1030: The nurse reviews the client’s information received in the report. Client admitted to surgical floor and placed in a semi-private room. Client returned from a trip to Mexico yesterday abdominal cramping, diarrhea, and nausea. Client reports, “It must have been something I ate on have been so sick since I got back from my trip. It started last night with abdominal cramping, and became nauseous.” Client appears weak. Skin is diaphoretic and pale. Heart sounds $1 and $2 he sounds are clear to auscultation. Bowel sounds are hyperactive in all four quadrants. Abdomen is touch. +2 peripheral pulses. Client reports feeling nauseous and has had 125 mL of bile emesis in hour. Has no appetite and has not eaten since yesterday. Temperature 37.5 C (100.3. F), blood p 112/38 mm Hg, heart rate: 100/min, respiratory rate 22/min, oxygen saturation 91% on room air on oxygen at 2 L/min via nasal cannula. Client is alert and cooperative. Diagnosed with gastroent Peripheral IV catheter initiated in left forearm. IV maintenance fluids started with D5 1/2 NS at 12 Client reports headache and rates abdominal cramping at “5” on a 0 to 10 pain scale received hy mg PO at 0900, and prescribed loperamide 2 mg PO 1st dose, then 1 mg after each loose stool th Not to exceed 6 mg in 2 hr. Loperamide 2 mg PO administered at 0834. Stools are decreasing; ho remains very weak. Which of the following concerns should the nurse address while providing client care? (Sel apply.) Physiological: Pain Physiological: Fluid and Electrolyte OPhysiological: Elimination Physiological: Infection Physiological: Nutrition
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